Insurers must do more to prevent surprise medical bills

At a time of hyper-partisanship, there is one issue around which both Republicans and Democrats have coalesced: protecting health-care patients and ending surprise billing.

Since the beginning of the year, the House has held two hearings to discuss surprise billing, and this week, the Energy and Commerce Health Subcommittee will turn its focus on the issue. President Trump has also held several news conferences to highlight this problem. However, lost in all of the conversation is one critical element: The role that private insurers play in putting patients in the middle and jeopardizing access to life-saving care.

Across the health care system, some private insurers have been shirking their responsibility to adequately cover emergency health care, leaving patients stuck with large bills they weren’t expecting for care that was critically necessary to their health. Balance or surprise billing occurs when a patient’s insurance fails to cover the cost of care and holds the patient responsible for paying the balance — an issue that includes emergency room visits, air medical care, hospital stays, medicines and more. 

Put simply, surprise bills happen because insurance companies don’t want to pay for the cost of service.

If Congress truly wants to help patients avoid exorbitant health care costs, it must focus on addressing reimbursement shortfalls by both government-funded and private insurers.

Ninety percent of patients flown by air ambulance have suffered a serious cardiac event, like a stroke or heart attack, or another serious trauma. This type of transport can only take place if the attending medical professional or first responder on the scene determines that an air ambulance is necessary based on the patient’s condition and proximity to the closest most appropriate facility. Air ambulances never self-deploy – they go only when called. And yet, almost 50 percent of privately insured patients have their claim initially declined by their insurance company. According to the Association of Air Medical Services, in just under half of these denials, insurance company accountants essentially argue that the medical professional or EMT was wrong — that the transport was not medically necessary. We don’t believe insurance companies should be playing doctor after-the-fact.  

Another way insurers avoid paying patients’ bills is through narrow provider networks. Having fewer providers in-network may be good for insurance company profits, but it results in more patients receiving a balance bill from out-of-network providers. According to one analysis, over the 12 months starting in third-quarter 2017, health insurer’ net income grew by 19% ($25.8 billion). They attribute this in part to “lower utilization.” Insurers also use other tactics such as setting rates arbitrarily, underpaying, or sending checks directly to the patient. 

It need not be this way. According to testimony provided to the Montana legislature, covering emergency air medical services for all patients would cost only $1.70 as part of one’s monthly insurance premium. Similarly, a Kentucky study estimated that the increase in health insurance premiums would be between $0.92 and $3.69 per month. Emergency air medical transports are not a cost driver for health insurance, in fact, this life-saving service is less than one percent of all health care costs.

Air ambulance providers are doing their part to help patients avoid balance bills. They’ve established robust patient advocacy programs to help patients navigate the insurance appeals process, and in many cases, get what they are owed. Providers are also working to go in-network, and with increasing success. But if some private insurers still won’t step up to the plate as well, refusing to negotiate with emergency air providers, then Congress must intervene. 

The solution is two-fold. First, private insurers must cover emergency air medical services. Second, Congress must update Medicare reimbursement rates to reflect the true cost of care. On average, Medicare reimburses only about half the cost of an air medical flight. Because more than 70 percent of air medical transport patients are covered by these government programs (or have no insurance at all), emergency air medical transports are severely under-reimbursed for seven out of 10 transports. Combined with some insurers’ refusal to work with providers, and the entire system is simply unsustainable.

This week’s Energy and Commerce hearing is an important step in the process. We applaud their attention to the issue and encourage them to protect patients and preserve access.

Carter Johnson is the spokesperson for the Save Our Air Medical Resources (SOAR) Campaign, a national campaign dedicated to preserving access to emergency air medical services for Americans across the country.